Department of Environment and Natural Resources

Environmental Management Bureau

Reference No:
(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility Gaisano Capital Tacloban

Establishment/Facility Street # & Street Name: Justice Romualdez St.

Address Barangay: 13 City/Municipality: Tacloban City
(NOT the company of head
office) Province: Leyte
Name of
HEVA MANAGEMENT & DEVELOPMENT CORPORATION
Owner/Company
Street # & Street Name: ___
Address
(if address is not the same as Barangay: City/Municipality: ___
previous address)
Province:

Phone Number Fax Number

e-mail address

Philippine Standard Industry Classification Code No. ___

Type of Business/
Philippine Standard Industry Descriptor: ___
Industry Classification
___

CEO/President. Henry S. Gaisano

Tel #: 254-888 Fax #: ___
e-mail address: ___
Responsible Officer/s:
Plant Manager: Eleanor P. Mantalaba
Tel #: 09173268816 Fax #: ___
e-mail address: ___

Name. Elie T. Melano

Pollution Control
Officer
Tel #: 09303010809 Fax #: ___
e-mail address: ___

 single proprietorship  partnership

 private domestic corporation  government
Legal Classification
corporation
 Multi-national  ___

We hereby certify that the above information are true and correct.

Ms. Eleanor P. Mantalaba Elie T. Melano

Name/Signature of CEO/President Name/Signature of PCO
Name of Plant:
Reference No:

Department of Environment and Natural Resources

Environmental Management Bureau

QUARTERLY SELF-MONITORING REPORT

MODULE 1: GENERAL INFORMATION

Name of the Plant
Please provide the necessary revised, corrected or updated information not contained in your General
Information Sheet

Gaisano Capital Tacloban Main is a general merchandise and retail establishment. It is located
at Brgy. 13 Justice Romualdez Street, Tacloban City, Leyte & managed by corporate branch
manager.

(use additional sheet/s if necessary)

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

DENR Permits/Licenses/Clearances
Environmental
Permits Date of Issue Expiry Date
Laws
A/C No.
P.D. 984 New dp on New dp on
PO No. 18 –DP-G-0837-0057 process process
ECC 1 R8-0804-055-5012
PD 1586 ECC 2
ECC 3
DENR
Registry GR-R8-37-00108
ID
CCO
Registry
RA 6969
Importer
Clearance
No
Permit to
Transport
A/C No.
RA 8749
PO No. 15-POA-E0837-0128 June 22, 2015 June 22, 2020

Operation
Operating hours/day Operating days/week # of shift/day
Average 12hrs/day 7days 2
Maximum 12hrs/day 7days 2

Operation/Production/Capacity:
Average Daily Total Output this
n/a n/a
Production Output Quarter
Total Water
Total Electric
Consumption this
2687m3 Consumption this 490000 Kwh
Quarter (cubic
Quarter (KwH)
meters)
Please use additional sheet/s if necessary

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

Module 1: General Information page ____ of ____

Name of Plant:
Reference No:

MODULE 2: RA 6969

A. CCO Report (please accomplish this section for each chemical/substance)

Common Name/IUPAC/CAS Index Name. n/a ___

CAS No.: ___
Trade Name: ___

For importers only:

Import
Quantity Date of Quantity Country of Country of
Clearance Port of Entry
Requested Arrival Received* Origin Manufacture
No.
n/a n/a n/a n/a n/a n/a n/a

Total Quantity Requested Total Quantity Received

(annual) (annual)
* attach copy/s of Bill of Lading

For distributors (importers/non-importers)

Name of Client License No. Quantity Date of Distribution
n/a n/a n/a n/a

Total Quantity Distributed

For non-importer users:

Name of Distributor Quantity Date of Purchase
n/a n/a n/a

Total Quantity Purchased from Distributor

4
For producers

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Average Daily
Production Output n/a Total Output this Quarter n/a
Quantity of Stock n/a Quantity of Stock n/a
Inventory (Start of Inventory (End of
Quarter) Quarter)
Name of Buyer Quantity Date of Purchase
MY2 (odor eliminator) 3 gals. June 27, 2018
MY2(sebo attacker) 3 gals. July 27, 2018

Total Quantity Sold

Used in Production (please fill up only if chemical/substance is not main product)

Average Daily
Production Output
n/a Total Output this Quarter n/a
Average Quantity Used n/a Total Quantity Used this n/a
per month Quarter
Describe any changes in Production/Process/Operations:

Stock Inventory/Waste Chemical Generated:

Average Quantity of n/a Total Quantity of Waste n/a
Waste Chemical Chemical Generated this
Generated per month Quarter
Quantity of Stock n/a Quantity of Stock n/a
Inventory (Start of Inventory (End of
Quarter) Quarter)

Other Information:
Manner of handling  storage on-site  Treatment on-site
hazardous wastes  storage off-site  Treatment off-site

Changes in Safety  Yes (please attach copy of revised plan)

Management System  No
Chemical Substitute
Plan  Yes (please attach copy if not submitted/included in previous report/s or had been revised)
 No 5

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

B. Hazardous Wastes Generator

HW Generation:
Remaining HW from
HW HW Generated
HW No. HW Class HW Nature Previous Report
Cataloguing
Quantity Unit Quantity Unit
D407 Busted Solid Toxic 323 Pcs. 20 Pcs.
Lamps
I 101 Used oil Liquid Flammable 30 Ltrs
J201 Empty Solid Toxic 15 Pcs.
container’s

Waste Storage, Treatment and Disposal:(Please fill-up one table per HW)
HW No,: D407,I101,and J201 was stored in close cabinet and properly
labeled
HW Details Qty of HW Treated: Not yet treated for pick up of 3rd party Unit:
___
TSD Location: on site ___

Name: D407, J201 and I101

Storage ___
Method: Stored in Material Recovery Facilities

ID: Name: On Process

Transporter
Date: ___

ID: Name: On Process ___

Treater
Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

HW No,: ___
HW Details Qty of HW Treated: Unit: ___
TSD Location: ___

Name: ___
Storage
Method: ___

ID: Name: ___

Transporter
Date: ___
Treater
ID: Name: 6 ___

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Method: Date: ___

ID: Name: ___

Disposal
Date: Date: ___

On-Site Self Inspection of Storage Area:

Corrective Action Taken
Date Conducted Premises/Area Inspected Findings & Observations
(if any)
July 14, 2019 Power House Area are clean -
August 05, 2019 Waste Storage Area are clean -
Area are clean and
September 27, 2019 Waste Storage -
properly arranged

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

C. Hazardous Wastes Treater/Recycler

HW Stored and/or Untreated as of End of Quarter:

Type of
Transport Storage Time Table
Wastes Date of
HW Number Permit/Date Valid until Quantity Container/ for
Generator Transport
of Issue # of Treatment
containers
n/a n/a n/a n/a n/a n/a n/a n/a

HW Treated and/or Recycled as of End of Quarter:

Type &
Type of
Transport Quantity of
Type of Wastes Date of Treatment or
HW Number Permit/Date Quantity Recycled or
Wastes Generator Transport Recycling
of Issue Treated
Process
Product
n/a n/a n/a n/a n/a n/a n/a n/a

Residual Wastes Generated from the Treatment and/or Recycling Operation:

Process by Type of
Type of which the Storage Disposal Time Table for
HW Number Quantity
Wastes Wastes is Container/ Option Disposal
Generated # of containers
n/a n/a n/a n/a n/a n/a n/a

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

Module 2C: RA 6969 (Hazardous Wastes Treater/Recycler) page ____ of ____

Name of Plant:
Reference No:

MODULE 3: P.D. 984 (Water Pollution)

Water Pollution Data

Domestic wastewater Process wastewater
9.0m3/day
(cubic meters/day) (cubic meters/day)
Cooling water Others: ___________
9.0m3/day 6.5 m3/day
(cubic meters/day) (cubic meters/day)
Wash water, equipment Wash water, floor
13.0 m3/day
(m3/day) (cubic meters/day)

Record of Cost of Treatment (Separate entries for separate facilities)

Month 1 Month 2 Month 3
Person employed, (# of
employees)
n/a n/a n/a
Person employed, (cost) n/a n/a n/a
Cost of Chemicals used
by WTP
n/a n/a n/a
Utility Costs of WTP
(electricity & water)
n/a n/a n/a
Administrative and
Overhead Costs
n/a n/a n/a
Cost of operating in-
house laboratory
n/a n/a n/a
n/a n/a n/a
New/Additional
Investments in WTP
(Description)

Cost of New/Add n/a n/a n/a

Investments

WTP Discharge Location

Outlet
Location of the Outlet Name of Receiving Water Body
Number
1 City Sewer -
2
3
4
5

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Conventional Pollutants

Outlet No.

Effluent Oil & ________

BOD TSS Temp rise (name)
DATE Flow Rate Color pH Grease
(mg/L) (mg/L) (ºC)
(m3/day) (mg/L)
(unit)
Less
6/14/19 37.5 1.7 than 7.2 9.5
0.50

Please fill-up/accomplish separate form/s for other outlet/s.

10

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Wastewater Characteristics for Other Pollutants

Outlet No.
________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) ________
Effluent Flow FECAL
(name)
DATE
Rate (m3/day) NITRATE AMMONIA DO COLIFORM PHOSPHATE SURFACTANTS
)

6/14/2019 37.5m3/day 0.26 1.73 8.0 3.7 0.03 1.69

Please fill-up/accomplish separate form/s for other outlet/s.

Please use additional sheet/s if necessary.
11

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

Module 3: P.D. 984 (Water Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 4: R.A. 8749 (Air Pollution)

Summary of APSE/APCF
Process Equipment Location # of hrs of operations
1. n/a
2.
3.
4.
Fuel Burning Quantity # of hrs of
Location Fuel Used
Equipment Consumed operations
2nd floor power house Diesel 25 ltrs/hr
1. 1 unit 500 kva 225 ltrs
Caterpillar from July to 9 hrs
Generator September
2019
2nd floor power house Diesel 20 lrts/hr
2. 1 unit 750 kva 140 ltrs.
Caterpillar from July to 7 hrs
Generator September
2019
Pollution Control Facility Location # of hrs of operations
nd
1. Critical muffler with Insulation & 2 floor
aluminum cladding
2.
3.
4.

Cost of Treatment
Month 1 Month 2 Month 3
Cost of Person employed,
(salary)
n/a n/a n/a
Total Consumption of
Water (cubic meters)
n/a n/a n/a
Total Cost of chemicals
used (e.g., activated n/a n/a n/a
carbon, KMnO4)
Total Consumption of
n/a n/a n/a
Electricity (KwH)
Administrative and
n/a n/a n/a
Overhead Costs
Cost of operating in-
n/a n/a n/a
house laboratory, if any
n/a n/a n/a
Improvement or
modification, if any.
(Description)

Cost of improvement of n/a n/a n/a

modification

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

12

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Detailed Report of Air Emission Characteristics

Description/Location
of PCF
________ ________ ________ ________
Flow Rate CO NOx Particulates (name) (name) (name) (name)
DATE
(Ncm/day) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)
PCF 1,
5/2/2018 750 66.4 1133.4
KVA

PCF 3,
5/2/2018 500 50.7 710.8
KVA

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

Please fill-up/accomplish separate form/s for other PCF/s.

Please use additional sheet/s if necessary.
13

Module 4: RA 8749 (Air Pollution) page ____ of ____

Name of Plant:
Reference No:

MODULE 5: P.D. 1586

Ambient Air Quality Monitoring (if required as part of ECC conditions)
Description/Location
of Monitoring Station
________ ________ ________ ________
Noise CO NOx Particulates (name) (name) (name) (name)
DATE
Level (dB) (mg/Ncm) (mg/Ncm) (mg/Ncm)
(mg/Ncm) (mg/Ncm) (mg/Ncm) (mg/Ncm)

(Please accomplish one table per monitoring station.)

Ambient Water Quality Monitoring (if required as part of ECC conditions)

Description/Location
of Sampling Station
________ ________ ________ ________ ________ ________ ________ ________
(name) (name) (name) (name) (name) (name) (name) (name)
DATE
(unit) (unit) (unit) (unit) (unit) (unit) (unit) (unit)

(Please accomplish one table per sampling station.)

14

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Other ECC Conditions

Status of Compliance
ECC Condition/s Actions Taken
Yes No

1. Billboard 
2.Permit to Operate (PTO) 
3.Discharge Permit (DP) 
4.
5.
6.
Please use additional sheet/s if necessary.

Environmental Management Plan/Program

Status of
Enhancement/Mitigation Measures Implementation Actions Taken
Yes No
Regularly pullout &
1.Solid Waste 
Segregation
Properly stored &
2.Chemicals 
arranged
3.
4.
5.
6.
Please use additional sheet/s if necessary.

Solid Waste Characterization/Information:

Average Quantity of 2400 kilos/month Total Quantity of Solid 7200 kilos as of July
Solid Wastes Generated Wastes Generated this to September 2018
per month Quarter
Average Quantity of 2400 kilos/month Total Quantity of Solid 7200 kilos as of July
Solid Wastes Collected Wastes Collected this to September 2018
per month Quarter

Entity in charge of
collecting solid wastes
Solid waste management team (LGU)

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

Brief Description of Solid

Waste Management Plan
(e.g., waste reduction,
segregation, recycling)

15

Module 5: P.D. 1586 (EIS System) page ____ of ____

Name of Plant:
Reference No:

MODULE 6: OTHERS

Accidents & Emergency Records

Findings and
Date Area/Location Actions Taken Remarks
Observation

none

Personnel/Staff Training
# of Personnel
Date Conducted Course/Training Description
Trained

n/a n/a n/a

I hereby certify that the above information are true and correct.

Done this _________________________, in ________________________.

Mr. Elie T. Melano Ms. Eleanor P. Mantalaba

Name/Signature of PCO Name/Signature of CEO

SUBSCRIBED AND SWORN before me, a Notary Public, this ________ day of
______________________, affiants exhibiting to me their Community Tax Receipts:

Name CTR No. Issued at Issued on

_____________________ _____________ _______________ ______________
_____________________ _____________ _______________ ______________

16

Module 5: P.D. 1586 (EIS System) page ____ of ____